Skywork D328 at Bern on Dec 7th 2015, went off runway while backtracking for departure

Last Update: October 3, 2018 / 16:19:29 GMT/Zulu time

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Incident Facts

Date of incident
Dec 7, 2015

Classification
Report

Flight number
SX-206

Destination
Hamburg, Germany

Aircraft Registration
HB-AEO

Aircraft Type
DORNIER 328

ICAO Type Designator
D328

A Skywork Airlines Dornier Do-328, registration HB-AEO performing flight SX-206 from Bern (Switzerland) to Hamburg (Germany) with 14 passengers and 3 crew, had been delayed by about 30 minutes due to the weather conditions at the destination. In the meantime the forecast fog arrived at Bern. When the aircraft taxied out to backtrack runway 14 and line up for departure the visibility (RVR) reduced to 600 meters/2000 feet. The crew decided to use the icing speeds for departure rather than the prepared/briefed speeds, the first officer therefore used the electronic flight bag to calculate the speeds and advised the captain he was no longer looking outside. The captain did not see the yellow taxi lines that should guide him along the runway turn pad while rolling at about 20 knots over ground. When the captain realized he had lost situational awareness he applied brakes, the aircraft however overran the turn pad and came to a stop in the grass past the turn pad. There were no injuries and no damage.

Switzerland's SUST released their final report in German only (Editorial note: to serve the purpose of global prevention of the repeat of causes leading to an occurrence an additional timely release of all occurrence reports in the only world spanning aviation language English would be necessary, a German only release does not achieve this purpose as set by ICAO annex 13 and just forces many aviators to waste much more time and effort each in trying to understand the circumstances leading to the occurrence. Aviators operating internationally are required to read/speak English besides their local language, investigators need to be able to read/write/speak English to communicate with their counterparts all around the globe) concluding the probable causes of the serious incident were:

The serious incident consisted of a barely avoided collision with obstacles because the aircraft was taxiing to the takeoff position at a speed that was not adjusted to the marginal visibility, the loss of situation awareness by the crew so that the aircraft could not be stopped in time. As result the aircraft came to a stop just past the runway turn pad in grass and just before the approach lighting.

The following factors contributed to the serious incident:

- the priorities were not set in accordance with the situational needs
- runway turn pad edge lightning hard to detect

The SUST reported that the recovery of the aircraft was performed not according to the aircraft recovery manual. As result there were concerns the main gear could have been overstressed during recovery. The operator replaced the main gear following a computation of stresses encountered during recovery. The removed gear was examined by the manufacturer and found serviceable finding that the landing gear had not been stressed beyond limits during the recovery.

The SUST analysed that the turn pads and lightings are in accordance with the ICAO/EASA requirements. However, the situation is not satisfactory nonetheless as the turn pad is no longer part of the runway although providing the same specifications with respect to surface properties, load capacity and dimensions. Because of this aircraft are forced to taxi beyond the red runway end lights each time the turn pad is to be used. This contradicts the principle that red lines must not be passed, a clearance to pass the red runway end lights would not be issued by air traffic control.

In addition the edge lights of the turn pad were hard to detect, the approach lights runway 14 were dominant and was more of an eyecatcher in addition to the poor visibility.

The SUST analysed that the icings speeds were brought up by the first officer only after the captain had already steered the aircraft onto the runway center line backtracking runway 14 and tower had reported 600 meters RVR. Instead of simply turning the pages of the speed booklet (according to instruction on the active reference speed page to immediately have the relevant icing speed available) the first officer engaged into computing the speeds via his electronic flight bag, while the low visibility required the attention of both pilots for taxiing.

In the meantime the captain accelerated the aircraft up to 30 knots over ground. The first officer did not monitor the progress of the taxi while being busy to compute the icing speeds and subsequently put them into the flight management system. This lack of mutual supervision violated the closed loop principle and was not safety minded as the priority was not directed at safe taxiing. This further led that the exact position of the aircraft was no longer known and the loss of situational awareness. When the captain noticed he had lost situational awareness, he applied brakes - this decision was correct - however due to the high speed over ground it was no longer possible to stop the aircraft within the paved surface of runway/turn pad.
Aircraft Registration Data
Registration mark
HB-AEO
Country of Registration
Switzerland
Date of Registration
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Certification Basis
Airworthyness Category
Pqhgmpifnljfbmpb Subscribe to unlock
Legal Basis
TCDS Ident. No.
Manufacturer
DORNIER LUFTFAHRT GMBH
Aircraft Model / Type
DO 328-100
ICAO Aircraft Type
D328
Year of Manufacture
Serial Number
Aircraft Address / Mode S Code (HEX)
Max. Operational Passenger Seating Capacity (MOPSC), indicative
Minimum Crew
Maximum Take off Mass (MTOM) [kg]
Engine Count
Engine
Incident Facts

Date of incident
Dec 7, 2015

Classification
Report

Flight number
SX-206

Destination
Hamburg, Germany

Aircraft Registration
HB-AEO

Aircraft Type
DORNIER 328

ICAO Type Designator
D328

This article is published under license from Avherald.com. © of text by Avherald.com.
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